Valveless Trocar Versus Standard Pneumoperitoneum Insufflation System in Minimally Invasive Surgery: Impact on Postoperative Pain. A Systematic Review and Meta-Analysis.

Background: The benefits of a valid pneumoperitoneum in laparoscopic surgery are counterbalanced by the possible negative effects of increased abdominal pressure and carbon dioxide (CO2) insufflation, which are crucial factors in causing postoperative pain. The purpose of this work is to evaluate the effectiveness of the valveless trocar (VT) insufflation system in decreasing postoperative pain and influencing operative time, compared to a standard insufflation system. Methods: A systematic research was performed using MEDLINE, EMBASE, Central Cochrane Library, and CINAHL Plus for studies published up to June 2020. Randomized controlled trials (RCTs) on adult population evaluating the effects of VT versus a standard insufflation system in laparoscopic surgery and reporting postoperative pain level and operative time were included in the analysis. Data and study quality indicators were extracted independently by 2 authors using a standardized form. Statistical analysis was based on a random effect model, using the inverse variance method. Results: We identified 3 RCTs for a total of 245 patients. The meta-analysis showed a statistically significant reduction in shoulder pain with the use of VT at 24 hours: mean difference (MD) -7.9% (95% confidence interval [95% CI]: -1.29 to 0.29; z = 3.08; P = .002) and a nonstatistically significant increase in operation time: MD 5.80 (95% CI: -8.93 to 20.54; P = .44). Conclusion: Our study suggests a better shoulder pain control at 24 hours postoperation using new-generation VT for laparoscopic surgery compared to standard insufflation system. Weak evidence of increased operating time with the VT was observed considering only two of the three RCTs. PROSPERO registration number: CRD42020191835.

The Effects of Ultrasound-Guided Transversus Abdominis Plane Block on Acute and Chronic Postsurgical Pain After Robotic Partial Nephrectomy: A Prospective Randomized Clinical Trial.

BACKGROUND: Use of a locoregional analgesia technique, such as the ultrasound-guided transversus abdominis plane block (TAPb), can improve postoperative pain management. We investigated the role of TAPb in robotic partial nephrectomy, a surgery burdened by severe postoperative pain. METHODS: In this prospective trial, patients with American Society of Anesthesiologists class I-III physical status undergoing robotic partial nephrectomy were randomly assigned to standard general anesthetic plus ultrasound-guided TAPb (TAP group) or sole standard general anesthetic (NO-TAP group). The primary end point was morphine consumption 24 hours after surgery. Secondary outcomes were postoperative nausea and vomiting in the first 24 hours, sensitivity, and acute and chronic pain, as measured by multiple indicators. RESULTS: A total of 96 patients were evaluated: 48 patients in the TAP group and 48 in the NO-TAP group. Median morphine consumption after 24 hours was higher in the NO-TAP group compared with the TAP group (14.1 ± 4.5 mg vs 10.6 ± 4.6, P < 0.008). The intensity of acute somatic pain and the presence of chronic pain at three and six months were higher in the NO-TAP group. CONCLUSIONS: Our results show that TAPb can significantly reduce morphine consumption and somatic pain, but not visceral pain. TAPb reduced the incidence of chronic pain.

Recovery from Anesthesia after Robotic-Assisted Radical Cystectomy: Two Different Reversals of Neuromuscular Blockade.

During robot-assisted radical cystectomy (RARC), specific surgical conditions (a steep Trendelenburg position, prolonged pneumoperitoneum, effective myoresolution until the final stages of surgery) can seriously impair the outcomes. The aim of the study was to evaluate the incidence of postoperative nausea and vomiting (PONV) and ileus and the quality of cognitive function at the awakening in two groups of patients undergoing different reversals. In this randomized trial, patients that were American Society of Anesthesiologists physical status (ASA) ≤III candidates for RARC for bladder cancer were randomized into two groups: In the sugammadex (S) group, patients received 2 mg/kg of sugammadex as reversal of neuromuscolar blockade; in the neostigmine (N) group, antagonization was obtained with neostigmine 0.04 mg/kg + atropine 0.02 mg/kg. PONV was evaluated at 30 min, 6 and 24 h after anesthesia. Postoperative cognitive functions and time to resumption of intestinal transit were also investigated. A total of 109 patients were analyzed (54 in the S group and 55 in the N group). The incidence of early PONV was lower in the S group but not statistically significant (S group 25.9% vs. N group 29%; p = 0.711). The Mini-Mental State test mean value was higher in the S group vs. the N group (1 h after surgery: 29.3 (29; 30) vs. 27.6 (27; 30), p = 0.007; 4 h after surgery: 29.5 (30; 30) vs. 28.4 (28; 30), p = 0.05). We did not observe a significant decrease of the PONV after sugammadex administration versus neostigmine use. The Mini-Mental State test mean value was greater in the S group.

Joint consensus on anesthesia in urologic and gynecologic robotic surgery: specific issues in management from a task force of the SIAARTI, SIGO, and SIU.

INTRODUCTION: Proper management of patients undergoing robotic-assisted urologic and gynecologic surgery must consider a series of peculiarities in the procedures for anesthesiology, critical care medicine, respiratory care, and pain management. Although the indications for robotic-assisted urogynecologic surgeries have increased in recent years, specific guidance documents are still lacking. EVIDENCE ACQUISITION: A multidisciplinary group including anesthesiologists, gynecologists, urologists, and a clinical epidemiologist systematically reviewed the relevant literature and provided a set of recommendations and unmet needs on peculiar aspects of anesthesia in this field. EVIDENCE SYNTHESIS: Nine core contents were identified, according to their requirements in urogynecologic robotic-assisted surgery: patient position, pneumoperitoneum and ventilation strategies, hemodynamic variations and fluid therapy, neuromuscular block, renal surgery and prevention of acute kidney injury, monitoring the Department of anesthesia, postoperative delirium and cognitive dysfunction, prevention of postoperative nausea and vomiting, and pain management in endometriosis. CONCLUSIONS: This consensus document provides guidance for the management of urologic and gynecologic patients scheduled for robotic-assisted surgery. Moreover, the identified unmet needs highlight the requirement for further prospective randomized studies.

Impact of a goal-directed fluid therapy on length of hospital stay and costs of hepatobiliarypancreatic surgery: a prospective observational study.

AIM: The effectiveness of goal-directed fluid therapy (GDFT) algorithms in improving postoperative outcomes has extensively been suggested. Nevertheless, there is a lack of strong evidence regarding both the clinical impact and the cost-effectiveness of the GDFT protocols. The aim of this study is to evaluate the costs of patients undergoing hepatobiliopancreatic surgery when a GDFT protocol is applied. Materials & methods: Consecutive ASA I-III patients undergoing hepatobiliopancreatic surgery were included in this prospective observational study. Depending on device availability, patients were handled either by fluid therapy guided by Vigileo monitor-derived hemodynamic variables (Vigileo-GDFT group) or by standard fluid treatment (standard group). Postoperative length of stay and economic costs were analyzed. RESULTS: In total, 147 patients were included (71 in the Vigileo-GDFT group and 76 in the standard group). The total hospital length of stay was 13 (median, 1st-3rd quartile, 9-20) days for the Vigileo-GDFT group and 14 (8-21) days for the standard group (p = 0.58); no statistically significant differences between the two groups emerged regarding costs and postoperative complications. In both groups, complications were the main contributor to total cost sustained. CONCLUSION: The application of a GDFT algorithm did not reduce the total length of hospital stay and the global costs, which were mainly influenced by the number of complications.

Acquired Hemophilia A After Hepatic Yttrium-90 Radioembolization: A Case Report.

Acquired hemophilia is a rare but potentially life-threatening bleeding disorder caused by the development of autoantibodies (inhibitors) directed against plasma coagulation factors, most frequently factor VIII. We report a case of a 65-year-old man with hepatocellular carcinoma who bled massively after a hepatic Yttrium-90 radioembolization procedure (Selective Internal Radiation Therapy with Yttrium-90 Resin Microspheres [SIRTex]). An acquired deficiency of factor VIII was diagnosed and successfully treated with recombinant activated factor VII and immunosuppression.

A Prospective, Randomized, Clinical Trial on the Effects of a Valveless Trocar on Respiratory Mechanics During Robotic Radical Cystectomy: A Pilot Study.

BACKGROUND: Prolonged pneumoperitoneum and Trendelenburg positioning for robot-assisted radical cystectomy (RARC) are essential for optimizing visualization of the operative field, although they worsen hemodynamic and respiratory function. Our hypothesis is that the use of a valveless trocar (VT) may improve respiratory mechanics. METHODS: In this prospective, 2-arm parallel trial, patients ASA II to III undergoing RARC were randomly assigned into 2 groups: in the VT group, the capnoperitoneum was maintained with a VT; in the control group, the capnoperitoneum was maintained with a standard trocar (ST group). Inspiratory plateau pressure (Pplat), static compliance (Cstat), minute volume (MV), tidal volume (Vt), and carbon dioxide (CO2) elimination rate were recorded at these times: 15 minutes after anesthesia induction (T0), 10 minutes (T1) and 60 minutes (T2) after first robot docking, 10 minutes before first undocking (T3), 10 minutes (T4) and 60 minutes (T5) after second docking, 10 minutes before second undocking (T6), and 10 minutes before extubation (T7). The primary end point of the study was the assessment of Pplat mean value from T1 to T6. RESULTS: A total of 56 patients were evaluated: 28 patients in the VT group and 28 in the ST group. VT group had lower Pplat (means and standard error, VT group 30 [0.66] versus ST group 34 [0.66] cm H2O, with estimated mean difference and 95% confidence interval, -4.1 [-5.9 to -2.2], P < .01), lower MV (means and standard error, VT group 8.2 [0.22] versus ST group 9.8 [0.21] L min, P < .01), lower CO2 elimination rate (means and standard error, VT group 4.2 [0.25] versus ST group 5.4 [0.24] mL kg min, P < .01), lower end-tidal CO2 (ETCO2) (means and standard error, VT group 28.8 [0.48] versus ST group 31.3 [0.46] mm Hg, P < .01), and higher Cstat (means and standard error, VT group 26 [0.9] versus ST group 22.1 [0.9] mL cm H2O, P < .01). Both groups had similar Vt (P = .24). CONCLUSIONS: During RARC, use of a VT was associated with a significantly lower Pplat and improvement in other respiratory parameters.

Protective effect of sevoflurane preconditioning on ischemia-reperfusion injury in patients undergoing reconstructive plastic surgery with microsurgical flap, a randomized controlled trial.

BACKGROUND: In many clinical conditions that involve free flaps and tissue transplantations the possibility of minimizing ischemia-reperfusion injury can be a determinant factor for the success of the surgery itself. We hypothesize that preconditioning with sevoflurane is a protective factor against ischemia-reperfusion injury. METHODS: In this randomized controlled trial, patients ASA I-II undergoing breast reconstruction with deep inferior epigastric perforator flaps were allocated into two groups and analyzed: group BAL included patients who received balanced anesthesia with sevoflurane for 30 min before removal of the flap and throughout the surgery. The TCI group included patients who received a total intravenous anesthesia with propofol and remifentanil. We evaluated regional tissue oximetry at the end of the surgery and at 4, 12 and 20 h after surgery. Other assessed parameters were: blood lactate clearance, alanine aminotransferase, aspartate aminotransferase, lactic dehydrogenase, creatine phosphokinase. RESULTS: In total 54 patients, twenty-seven per group, were analyzed. There was a significant increase of the average value of regional tissue oximetry measured 4 h after surgery in the BAL group compared to the TCI group: BAL: 84.05 % (8.96 SD); TCI : 76.17 % (12.92 SD) (P = 0.03), but not at the other time frames. The creatine phosphokinase value was significantly lower in the BAL group at the end of surgery, but not at the other time-frames. There were no significant differences in blood levels of other markers. CONCLUSIONS: From our results, the positive preconditioning impact of sevoflurane on ischemia-reperfusion injury in patients undergoing free flap surgery is expressed in the early postoperative hours, but it does not persist in the long-term. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT01905501 . Registered July 18, 2013.

Preperitoneal Continuous Infusion of Local Anesthetics: What Is the Impact on Surgical Wound Infections in Humans?

OBJECTIVE: Continuous surgical wound infusion with local anesthetics is an effective and widely used technique in postoperative pain management. Some aspects of this technique, however, require further investigation. The aim of this study was to retrospectively assess whether continuous infusion of ropivacaine delays the process of wound healing, with an increased incidence of infection. DESIGN: In total, 244 patients aged between 18 and 75 years, American society of anesthesiology II-III, underwent hepatobiliary pancreatic surgery, were classified into two groups and retrospectively analyzed: group R (Ropivacaine) included 152 patients whose surgical incision was fitted with a preperitoneal catheter continuously infusing ropivacaine. Group C (Control) included 92 patients receiving a total intravenous postoperative analgesia. The evaluation forms of the surgical wound according to the Southampton wound assessment scale (SWAS) were collected at three time points. The main outcome was the rate of patients with surgical site infection within 30 days postoperatively. RESULTS: Twenty-one patients (13.8%) in group R and 9 patients (9.8%) in group C (P = 0.35) presented wound infection. The rate of patients with a wound evaluation of a SWAS grade IV or V in three time frames in Group R and Group C was T0, 1 (0.7%) and 1 (1.08%) (P = 0.72); T1, 25 (16.4%) and 7 (7.6%) (P = 0.04); T2, 8 (5.3%) and 5 (5.4%) (P = 0.53), respectively.onclusions. The incidence of infection in the surgical site according to the centers for disease control definition was comparable in both groups. The description of the wound healing process according to the SWAS scale shows an initial and temporary decrease in maturation in group R which does not persist in the long-term.

A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II-III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5% in GDT group and 38.1% in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs. 9.5% in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs. 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol.

Perioperative changes in pro and anticoagulant factors in prostate cancer patients undergoing laparoscopic and robotic radical prostatectomy with different anaesthetic techniques.

BACKGROUND: Laparoscopic prostatectomy (LRP) may activate clotting system influencing the risk of perioperative thrombosis in patients with prostate cancer. Moreover, different anaesthetic techniques can also modify coagulant factors. Thus, the aim of this study was to investigate the effects on pro- and anti-coagulant and fibrinolytic factors of two established types of anaesthesia in patients with prostate cancer undergoing elective LRP. METHODS: 102 patients with primary prostate cancer, who underwent conventional LRP or robot-assisted laparoscopic prostatectomy (RALP), were studied and divided into 2 groups to receive total intravenous anesthesia with target-controlled infusion (TIVA-TCI) or balanced inhalation anaesthesia (BAL) prior to surgery. Before the induction of anaesthesia (T0), 1 hr (T1) and 24 hrs post-surgery (T2), some pro-coagulant factors, fibronolysis markers, p-selectin and haemostatic system inhibitors were evaluated. RESULTS: Both TIVA-TCI and BAL patients showed a marked and significant increase in pro-coagulant factors and consequent reduction in haemostatic system inhibitors in the early post operative period (p ≤ 0.004 for each markers). Use of RALP showed a significant increase in prothrombotic markers as compared to LRP. In TIVA patients undergoing LRP, a significant reduction of p-selectin levels between T0 and T2 (p = 0.001) was observed as compared to BAL, suggesting a better protective effect on platelet activation of anaesthetic agents used for TIVA. CONCLUSIONS: Both anaesthetic techniques significantly seem to increase the risk of thrombosis in prostate cancer patients undergoing LRP, mainly when the robotic device was utilized, encouraging the use of a peri-operative thromboembolic prophylaxis in these patients.

Immunomodulatory effects of total intravenous and balanced inhalation anesthesia in patients with bladder cancer undergoing elective radical cystectomy: preliminary results.

BACKGROUND: Although surgery and anesthesia induce immunesuppression, remains largely unknown whether various anesthetic techniques have different immunosuppressive effects on cancer patients. Therefore, the aim of this study was to investigate the influence of total intravenous anesthesia with target-controlled infusion (TIVA-TCI) and balanced inhalation anesthesia (BAL) on the peri-operative levels of inflammatory cytokines and regulatory T cells (Tregs) in patients with bladder cancer undergoing surgery. METHODS: Twenty eight consecutive patients with bladder cancer who underwent radical cystectomy were prospectively randomized into two groups to receive TIVA-TCI (n = 14) or BAL (n = 14). Before the induction of anesthesia (T0), 6-8 hours (T1) post-surgery, and 5 days post-surgery (T2), Tregs and serum levels of interleukin -1beta (IL-1ß), interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin -2 (IL-2), interleukin -6 (IL-6), and interleukin -10 (IL-10) were measured. RESULTS: In the peri-operative period all cancer patients showed a marked and significant increase in IL-6. Moreover, TIVA-TCI patients also showed a higher increase in IFN-γ, whereas in BAL patients Tregs were reduced by approximately 30% during surgery. The incidence of infections, metastases, and death was similar in both groups. CONCLUSIONS: The increase in the Th1 response in the TIVA-TCI group and the reduction in Tregs in the BAL group seem to balance the immunosuppressive effect induced by IL-6. Therefore TIVA-TCI and BAL can be both used in major surgery in patients with bladder cancer without worsening the outcome.

Evaluation of renal function under controlled hypotension in zero ischemia robotic assisted partial nephrectomy.

BACKGROUND/AIMS: In partial nephrectomy with hilar clamping every minute of ischemia can impair renal function, thus great importance is having the controlled hypotension as a part of zero ischemia technique. The aim of the study is to evaluate the effects of hypotensive anesthesia on renal function, in patients undergoing robotic assisted partial nephrectomy (RAPN) , during surgery and at 3 months follow up. METHODS: This is a prospective study of 100 patients, ASA 1-2, who underwent zero ischemia RAPN under controlled hypotension (CH) from December 2011 through to May 2013. Serum creatinine, BUN, estimated glomerular filtration rates (eGFR), fractional excretion of sodium (FSE) and technetium Tc 99m mercaptoacetyltriglycine (99mTC-MAG-3), renal scintigraphy with effective renal plasma flow (ERPF) were evaluated. RESULTS: Mean duration of CH was 50 ± 4 minutes. Acute renal failure wasn't observed in any of the patients. A significant variation of eGFR during the procedure and 24 hours after surgery was observed. No significant variation of BUN and FSE was detected. Comparing preoperative ERPF of the operated kidney with ERPF 3 months after surgery, it decreased by 2%. CONCLUSION: In patients with normal preoperative renal function CH didn't show any detrimental impact on renal function during and after robotic assisted partial nephrectomy.